EmailMeForm
LU Employment Academy Prep Class Registration Form
Complete the form below. We will contact you with more information and instructions.
Lincoln University Adult Education and Literacy
812 East Dunklin Street
Jefferson City MO 65101
573-659-3122
Please select your preferred career track
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Office Administration
Accounting Associate
Cyber Security
Direct Care
Name:
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First
Last
Social Security Number
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XXX-XX-XXXX
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone:
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Email:
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Birthday:
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MM
/
DD
/
YYYY
AGE:
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Best time to call:
Morning
Afternoon
Evening
Preferred Method of Contact:
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Phone call
Email
Gender:
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Female
Male
Choose not to disclose
Race:
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American Indian or Alaskan
Asain
Black or African American
Native Hawaiian/Pacific Islander
White
Hispanic?
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Yes
No
Labor Force:
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Employed
Unemployed
Not in Labor Force
Highest Level of Education:
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No Schooling
Grades 1-5
Grades 6-8
Grades 0-12 (no diploma)
High School Equivalency Certificate
Some Postsecondary, no degree
Postsecondary/Professional Degree
Unknown
Location of Highest Level of Education
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United States Based
Non U.S. Based
Do you have a college degree?
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Yes
No
What is your college degree?
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Associate Degree
Bachelor's Degree
Master's Degree
PHD
None
Barriers to Employment:
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Cultural Barriers
Disabled Individual
Displaced Homemaker
Low Income
English Language Learner
Ex-offender
Exhausting TANF within 2 years
Youth in Foster Care
Homeless
Long-term Unemployed (27 or more weeks)
Low Literacy Levels
Migrant Farmworker
Seasonal Farmworker
Single Parent/Guardian
Referred by:
Community Action Agency
Missouri Job Center
Vocational Rehabilitation
Probation and Parole
Family Services Division
Other
I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I consent to the release of my records maintained by a state or local education agency, including the information on this form and transcripts, grades, certificates, the High School Equivalency, and diplomas earned by me. This information may be used by the Missouri Department of Elementary and Secondary Education and shared with other state agencies for research and reporting purposes. Data shared between agencies includes, but is not limitd to, employment, additional schooling and follow-up servicesprovided to you by agencies indentified in the Workforce innovation and Opportunity Act (2014). Currently, as of this date, I am not enrooled in a secondary school institution or receiving homeschool services.
Signature
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Clear
Date Time
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MM
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DD
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YYYY